Application Test Page Family Application Name: First Last Address: Street Address Address Line 2 City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Best Time To Call:Email:Her Occupation:Work Phone:Place of Employment: Cell Phone:Email:His Occupation:Work Phone:Place of Employment: Cell Phone:Email:Emergency Contact (other then parents): First Last Phone:Position that you would like us to help you fill: Nanny Full-Time Nanny Part-Time Summer Nanny Pet Care Newborn Caregiver Nanny Compassionate Companion (elderly non-medical) Mother's Helper Childcare Overnights Group Care Childcare Call-In Day Care Back-up Wedding or Event Nanny Children: (Please complete if requesting services for children)Name:Age:Date of Birth:Male or Female: Click The "+" To Add More ChildrenDo Any of Your Children Have Any Special Needs? Yes No If yes, please explain:If your children are in school what hours do they attend school? Do any other family members or friends live in your home (grandparents, aunts, uncles, etc. )? Yes No Will they be there when the caregiver is present? Yes No If yes, please describe the situation:Does anyone in your home smoke? Yes No Compassionate Companion (elderly non-medical care, short term disability):Name:Age:Date of Birth: Click The "+" To Add More Do any of these individual(s) have any special needs? Yes No If yes, please explain:Pet CareName:Kind of Pet:Age:Date of Birth:Male or Female: Click The "+" To Add More Do any of your pet(s) have any special needs? Yes No If yes, please explain:Below applies to all services requested:Start Date requested:Kind of service:Salary offered: Benefits offered (paid vacation, sick days, health care): Required hours and days: What skills and abilities would you like to have in your employee?Will your empoyee need to drive your children/elderly/pet? Yes No If yes, will your caregiver need to supply a car? Yes Car will be supplied If car will be supplied: Automatic Manual Would you employ a nannay/caregiver that brought their own child? Yes No Would you allow your caregiver to take your children/elderly on outings? Yes No If yes, what kind of outings would you like your caregiver to provide?Do you require the caregiver to cook for: Children Elderly Family All of the above Do you require the caregiver to do laundry for: Children Elderly Family All of the above What other kinds of errands would you like your caregiver to do?(pick up/drop off kids from activities, pick up prescriptions, take pet to vet, drop of dry cleaning, etc.)Do you have any other comments at this time that you feel you should add?How did you hear about Nanny Nexus?Nanny Nexus Full-Time/Part-Time Nanny Services Client Understanding and Release:Understanding between parties: 1. Nanny Nexus agrees to make its best effort to locate child caregivers for client's child care needs on requested basis. 2. Client agrees to pay caregivers directly for services rendered at least. 3. Client understands that the services provided by all caregivers referred by The Agency must be contracted through The Agency office. Client further understands that the use of an Agency caregiver, or referral of an Agency to a third party, without arranging the visit through the agency, is considered "theft of services" and will result in a charge of $2,500 for liquidated damages. 4. In the event that Client wishes to hire a nanny referred by Nanny Nexus on a permanent basis client agrees to pay Nanny Nexus placement fee for a permanent Caregiver ("Nanny") is $1,400 for a part-time/full-time nanny. Client understands that caregivers working with Nanny Nexus are not employees of Nanny Nexus. Client understands that if they pay more than the allotted government amount per calendar year to anyone caregiver s/he is responsible for withholding and filing employment taxes for that person. Social Security number of caregivers must be obtained directly from caregivers. 5. Client agrees to forever indemnify, release and hold harmless Nanny Nexus its agents, employees, and officers for any and all claims relating to services provided by caregivers. Nanny Nexus does not provide a refund for services already rendered. By typing your name and submitting the form as completed above, you agree that you have read and agree with the information on this form. You also agree to comply with it, and agree to pay any applicable fees, listed above. Full Name: Date Application Completed: MM slash DD slash YYYY * I agree that all of the information on this application is true to the best of my knowledge.